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HomeMy WebLinkAboutApp-Permit-Compliance�r ��- No. COMMONWULT14 Of MASSACHUSETTS Board of Health,�49-t- O w,rr - , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade f/) Abandon()-Pomplete System ❑ Individual Components Location 7 jv14d (,(i 00 W%%, to l�flm , Owner's Name Map/Parcel# 31 Z/JV Address / )E44 4 j e v rT S/ LI dA dM ZVV f Lot# Telephone# (.4- l 11 0a a d Installer's Name C e s-e"Vam/mj Zoe, Designer's Name f e C Address N 6 p Address g d 3 Tt r �/;V , gy m /3 0,�6 Telephone# scb e-3 M-Wc ITOF w, /o/0 Telephone# zo Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS J -ee- Date of Evaluation Z, C, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the sys em in eration until a Certificate of ompliance has been issued by the Board of Health. Signed Date 6 6 n k , _ L , , ii z _ No. ! - _ v FEE i COMMONWEALT14 OF MASSAC14USETTS d4 I :z s //,r Board of Health, o t MA. / CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s)Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.Upgraded (i) -Abandoned ( ) by: lr rI T '. /j/ 4'2 , f (-. at 7A has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to application No. _ `.�- dated 7— l` �. Approved Design Flow and Installer `r `Y S jy I ' _ Designer. �; % #. kip f i Inspector: ii Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. _ ( L" //BGG FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, ) (6 (LM6 0714 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade (;,.r Abandon( ) an individual sewage disposal system at I',`.''. r - ,j I i - as described in the application for } Disposal System Construction Permit No. 2"_, dated 7 Provided: Construction shall be completed.withinAi�1df the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date 7 // Board of Health